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Physician Referral Form

To refer a patient to SCCA, call (206) 288-SCCA (7222) or complete the form below. SCCA also offers U-Link, a secure system that allows referring physicians access to information about their patients. (* denotes required field). Download this PDF to view the complete list of SCCA/UW oncology providers by specialty.

Referring Physician

*Your Full Name:

*Phone Number:

Fax Number:

*E-Mail Address:

Please check here if you are an SCCA Network Physician

Patient Details

*Full Name:

*Date of Birth:

*Patient Phone Number:

*Patient Insurance:

*Diagnosis:

*Management of Care

Please assume complete management of patient.

Please assume a subset of care. We have developed a plan for the patient and would like you to review for input.

We would like your opinion only.

Please screen this patient for the following Phase 1 Program trial at SCCA:

BMS-986016 for Relapsed or Refractory Chronic Lymphocytic Leukemia and Lymphomas (13045)(13045)
A Phase 1 Dose Escalation and Cohort Expansion Study of the Safety, Tolerability, and Efficacy of Anti-LAG-3 (BMS-986016) in Relapsed or Refractory Chronic Lymphocytic Leukemia and Lymphomas

Files should include medical records pertaining to the patient's original diagnosis through present and any treatment thus far. This includes chart notes, pathology reports, and radiology reports, laboratory reports for the last six months, surgical reports and treatment reports/summaries (ie: chemo flow sheets, radiation treatment reports).